In this issue:

 A Closer Look at the Landmark 'No-Ventilation' CPR Study

Inhaled Insulin Effective

Avoiding Hypotension in Rapid Sequence Intubation

Swimming Pool-Related Diarrhea Outbreaks are Increasing

E-Mail Scams

Computer Evolutions

Web Sites of Possible Interest

Quotable Quotes

ERDOCS listserv

How to get in touch with us; questions; sponsorship

A Closer Look at the Landmark 'No-Ventilation' CPR Study

With the release of new ACLS and BCLS standards late in 2000, came an oft-cited study looking at conventional versus no-ventilation CPR. Biostatisticians involved in the study are concerned about misconceptions emerging from those not looking carefully at the parameters of the findings.

The study looked at 241 patients in Seattle that received chest compressions alone (CA), while another 279 patients received compressions and ventilations (CV). Bystanders untrained in CPR performed the skills as instructed to do so over the telephone by trained emergency medical dispatchers. The resulting survival-to-hospital admission (40.1% of CA group, 33.5% of CV group) and the hospital discharge rates (14.6% of CA and 10.4% of CV group) slightly (but not statistically) favored the compressions-only group. Press coverage focused on the apparent lack of a need to ventilate CPR patients. This has led to some confusion among public and health care professionals. What wasn't as evident was the following;

Dispatchers took 1.4 minutes longer to include ventilations in their telephone CPR instructions.

Dispatchers completed instructions for 81% of the chest compressions-only rescuers, while completing them only 62% of the time when coaching conventional CPR instruction. Completion was most typically interrupted by arrival of professional rescuers. (This also emphasizes the rapid response of the EMS system in the area).

Callers that were receiving conventional compressions-and-ventilations CPR instruction were almost three times as likely to hang up or declare the instruction too difficult (7.2% versus 2.9%).

Conclusions about the impact and legacy of the study need to be tempered with the context: teaching CPR over the phone to inexperienced providers in rapid EMS response systems. As one prominent EMS educator put it, "This study spoke only to the problems of a method of teaching CPR---by dispatchers on the telephone-not to the physiology of CPR…"

Inhaled Insulin Effective

An inhaled form of insulin continues to prove itself effective in controlling blood sugar levels in diabetics for at least two years without harming their lung functions, researchers reported recently.

The patients were treated with Exubera, a dry powder form of insulin being developed by Pfizer Inc. and Franco-German drug company Aventis SA . The insulin is absorbed into the body through an aerosol made by Inhale Therapeutic Systems Inc.

A two-year follow-up study of 140 patients who participated in one of three earlier mid-stage clinical trials of the inhaled insulin were presented at a meeting of the American Thoracic Society, recently in San Francisco.

Avoiding Hypotension in Rapid Sequence Intubation

A study in the April-June issue of Prehospital Care looks at the role that amounts greater than 5 mg of midazolam may play in the occurrence of hypotension as an aftereffect of rapid sequence intubation.

Using a retrospective review  performed on charts from the two aeromedical agencies servicing the Southern California region. The authors reported that the RSI protocols used by crews from the northern and the southern parts of the region were identical, with the exception of midazolam dosing. The north crews used 0.1 mg/kg for all patients, while the south crews used the same dose formula, but only to a maximum of 5 mg.

There were a total of 219 patients (northern = 75, southern = 144). Multiple linear regression revealed a statistically significant relationship between midazolam dose and both hypotension and systolic blood pressure decrease following RSI. There was no difference between north and south with regard to age, sex, incidence of traumatic brain injury, initial systolic blood pressure, or Glasgow Coma Scale.

In patients  weighing more than 50 kg, those from the northern service received higher midazolam doses and had a higher incidence of hypotension than those from the south.

Note: At least one central Iowa aeromedical team reportedly utilizes midazolam initially, followed 60 seconds later with Etomidate (0.5mg/kg) for preintubation sedation. Midazolam helps with event amnesia and minimizing the myoclonic side effects and peripheral infusion discomfort of Etomidate. Additional amounts of midazolam are optional following the procedure, based on the patient's tolerance of the procedure.

Popular Prescription Allergy Meds Recommended for Over-the Counter Status

On May 10th, a government advisory panel voted overwhelmingly to advise the Food and Drug Administration that Claritin, Allegra and Zyrtec should be available over-the-counter. The decision will likely pit drug manufacturers (currently taking in some $5billion a year) against health insurers, in determining the final outcome. Legal experts warn that the issue could potentially be tied up in courts for years.

Officials from Aventis S.A. (Allegra), Schering-Plough (Claritin), Pfizer Inc. (Zyrtec) expressed concerns over the proposal, while Dr. Robert Seidman, chief pharmacy officer of Wellpoint Health Networks, which brought the issue to the FDA, said the recommendations were history making. Advocates of the move point to Canada, Germany, Britain and other countries where Claritin has been sold without prescriptions for more than a decade at much lower prices. An example - the current price of Claritin is about $2.13 a pill ($192 for 90 pills), in the United States. In Canada, where it is available over-the-counter, it costs about 70 cents per pill before taxes.

Swimming Pool-Related Diarrhea Outbreaks are Increasing

The number of Americans who got diarrhea from swallowing fecal contaminated water in swimming pools and other recreational facilities rose in the 1990s, according to a report released by the CDC recently.

About 10,000 cases and 32 outbreaks of waterborne diarrhea [were] linked to pools, waterparks, spas, and other facilities in the United States from 1989 to 1998, according to the Centers for Disease Control and Prevention (CDC) in Atlanta. Almost a third of the decade's outbreaks occurred in the latest year data was acquired (1997-1998), compared to a single outbreak in the first year, 1989-1990.

The CDC said it was surprised to find that about 18 per cent of respondents in one state continued to swim while suffering from diarrhea. The CDC recommended that people refrain from swimming until two weeks after diarrhea has stopped. It added that outbreaks could be limited by improved public awareness of diarrhea and changes to swimming pool policies, such as the inclusion of bathroom breaks for kids and separate water filtration systems for children's pools.

Most of the recent outbreaks of diarrhea linked to swimming pools were caused by cryptosporidium, a microscopic chlorine-resistant parasite. However, a recent issue of CDC's Morbidity and Mortality Weekly Report includes a 1999 report that also noted the presence of giardia in several specimens obtained from pool fecal contamination accidents in the pools studied. Giardia is responsible for many cases of prolonged diarrhea and malabsorption. The report is available online at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5020a3.htm

New Breast Cancer Smart Probe Ready for Trials

In the U.S., each week approximately 16,000 women undergo surgical breast biopsies on suspicious tissue that turns out benign. In addition, it is estimated that physicians miss about 4,600 cases of breast cancer each week during physical examinations and mammogram
reviews.

Lawrence Livermore National Laboratory, in conjunction with BioLuminate, has created a breast cancer detection tool that "removes no tissue" and "expected to achieve accuracy levels comparable to surgical biopsies in detecting cancerous cells." By using the BioLuminate 'Smart Probe' before biopsies are performed on suspicious lesions, many unnecessary surgeries might be eliminated

The "Smart Probe" is a small needle-probe that is inserted into the breast that analyzes, in real time, using optical, electrical and chemical properties that are known to differ between healthy and cancerous tissues. The "Smart Probe" can detect multiple (5 to 7) known indicators of breast cancer, presenting results instantaneously.

Human trials are scheduled to begin this spring.

E-Mail Scams

Don't be taken in! Email hoaxes seem to constantly be surfacing regarding:

1. supposed virus alerts (even if the email says they're "confirmed by IBM, Microsoft, AOL and Oracle" or some such);

2. pending legislation, including email surcharges and taxes;

3. sick/dying/missing children who need email or prayers;

4. body part theft rings;

5. free vacation giveaways;

6. free money or products from Bill Gates (or Disney or AOL or Nokia or....) to those who forward the most email;

7. foreign government workers who will pay you to let them move large sums of money through your bank account;

8. or any of hundreds of similar chain letters.

These are ALL almost always pure, utter hoaxes and scams.

If you are not sure, check up on any claims before forwarding them.
There are any number of resources you can use, including:

Symantec Anti Virus Research Center
http://www.symantec.com/avcenter/index.html

McAfee Associates Virus Hoax List
http://vil.mcafee.com/hoax.asp?

Department of Energy Computer Incident Advisory Capability
http://ciac.llnl.gov/ciac/CIACHoaxes.html

Debunking online and email hoaxes
http://www.kumite.com/myths/

The Urban Legends Web Site
http://www.urbanlegends.com

Urban Legends Reference Pages
http://www.snopes.com

Datafellows Hoax Warnings
http://www.Europe.Datafellows.com/news/hoax.htm

Computer Evolutions

Increasing Chip Power
For the past 40 years, the pattern for computer chips has been projected onto wafers of silicon through huge, expensive lenses.  To create smaller circuits on the chips you simply used shorter wavelengths of light.  Adding mirrors to allow them to use even shorter wavelengths of light (extreme ultraviolet), may be the next breakthrough. Estimates are that this technology will create new chips that have 100 times the computing power and 1,000 times the storage capacity of today's best chips. We may be able to store an entire library on one of these new chips

A 400 Gigabyte Hard Drive Memory?
An announcement by IBM recently, regarding ruthenium,a new magnetic coating for CD-ROM May make for some incredible breakthroughs in gigabyte storage in the near future. Providing a thin layer of ruthenium (playfully referred to in the industry as "pixiedust") appears to be increasing data density. Speculation is that 400 Gb hard drives are possible within the next two years.

Web Sites of Possible Interest

Atlas of Human Embryology
http://humanembryology.com/

Human embryology is a study in the formation of the organs and processes from conception to birth. This site includes a number of illustrations that can be downloaded in .pdf format.

Jane's
http://www.janes.com/index.shtml

Jane's is the definitive source of defense, aerospace, and transportation information. Based on the Jane's series of defense magazines and the work of Fred T. Jane (1865-1916; writer of a series of defense manuals, and a respected sci-fi author and artist), the site keeps you up to date.

Sleep Postures and Personalities
http://www.sleepbest.com/habbit/frame-e.htm?/habbit/index-e.htm

A fun site that looks at what sleep postures allegedly reveal about our personalities; cute sound effects accompany the site.

Roadside Attractions and Unusual Sites
http://www.roadsideamerica.com/

This fun site has some extraordinary trivia and travel tips for off-the-beaten-path, Clark Griswold-type adventures. Recently featured stories include the Purple Martin Capital of the Nation, Crayola Factory, Jelly Belly Tour, QVC studio tour, Golgotha Bible Mini golf and the World's Largest Sycamore Stump.

Quotable Quotes

"Education is the path from cocky ignorance to miserable uncertainty."
     ---Mark Twain

"One learns in life to keep silent and draw one's own confusions."
   --- Cornelia Otis Skinner

Henry Kissinger -(1923-____) US government official ; 1973 Nobel Peace Prize:

"Next week there can't be any crisis. My schedule is already full."

"The absence of alternatives clears the mind marvelously."

"The nice thing about being a celebrity is that, if you bore people, they think it's their fault."

G. K. Chesterton-(1874-1936)poet,  essayist, novelist, journalist:

"The chief object of education is not to learn things but to unlearn things."

"Art, like morality, consists in drawing the line somewhere."

"One sees great things from the valley; only small things from the peak."

"The way to love anything is to realize that it might be lost."

ERDOCS e-mail group (listserv)

As a Clinician providing acute and emergency medical care, you are invited to visit and participate in our new ERDOCS group at eGroups, a free, easy-to-use email group service! You have plenty of experiences to share, questions to ask, concerns and opinions to voice, suggestions, news to post, tips to offer, etc. and can do so within this framework. this is a versatile system for posting things to be sent to a group to peruse, respond to, or simply be aware of. It eliminates conventional mail delays and allows you to review and post at your leisure. (We still have the more open-ended [any visitor can observe/post] discussion group at the ACUTE CARE, INC. web site). Our goal is to give you a variety of feedback and communication tools.

The manager/moderator for this ERDOCS egroup is the webmaster for the ACUTE CARE, INC. website (www.acutecare.com), Paul Hudson. You can subscribe by sending an e-mail indicating your wish to be included to Paul at paul@acutecare.com

As this site grows, it will feature news, calendars, links to references, resources, and other useful features. We hope you will support this effort to foster ongoing communication amongst EM providers.